After the American Health Care Act passed the House on Thursday, Republicans were quick to celebrate their hard-fought political victory.

“Welcome to the beginning of the end of Obamacare,” Vice President Mike Pence declared during a press conference in the White House rose garden.

President Donald Trump was similarly enthusiastic, saying “we’re going to get this past the Senate; I’m so confident.”

However, healthcare policy experts told Fierce Healthcare that the legislation, which the House passed on a razor-thin margin, will face an uphill battle on its journey to the president's desk.

“It’s very clear that what passed the House is not going to pass the Senate,” said Julius Hobson, a healthcare lobbyist and attorney with the Washington, D.C., law firm Polsinelli.

For one, the amendments made to the bill may not comply with the Senate’s so-called Byrd Rule that governs what can be included in a budget reconciliation measure, he said.

In addition, Hobson pointed out that members of the Senate have already suggested that they are going to start from scratch rather than take up the House version of the bill.

“I’ve talked to a couple of key senators on this,” he said, “and to the last one, they said, ‘we will definitely have amendments,’ sort of laughing, as if to say, you know, ‘we’re not taking up that crap.’”

Sally Pipes, president and CEO of the right-leaning Pacific Research Institute, also pointed out that conservative senators such as Rand Paul, Mike Lee and Ted Cruz might prove difficult to win over.

Thus, “I think that it could be changed significantly at the Senate level,” she said.

Major hurdle in Medicaid

One of the major sticking points, Hobson said, will not be the AHCA’s individual market changes—which were the focus of amendments to the bill—but rather what it has in store for the Medicaid program.

“Medicaid will be a bigger issue in the Senate than it was in the House,” Hobson predicted.

For example, Sen. Rob Portman, R-Ohio, and Sen. Lisa Murkowski, R-Alaska, whose states both embraced Medicaid expansion, have already come out against what the House did in terms of cuts to the program, he noted.

Vivian Ho, who chairs the health economics department at Rice’s Baker Institute for Public Policy, pointed out that only does the AHCA gut the Affordable Care Act’s Medicaid expansion, it also scales back the Medicaid program that existed pre-ACA.

Indeed, when it scored the original House bill, the Congressional Budget Office estimated that it would reduce Medicaid outlays by $880 billion in the next 10 years.

“This is going to put a tremendous burden on states to try and cover healthcare for low-income people who qualify for Medicaid,” she said. “It won’t look so bad at the beginning; it’s the way the law is written, it will compound year by year, and so within 10 years, these programs are going to be suffering a great deal.”

Even America’s Health Insurance Plans, the industry’s largest trade group, was concerned about the bill’s implications for the Medicaid program.

“The American Health Care Act needs important improvements to better protect low- and moderate-income families who rely on Medicaid or buy their own coverage,” AHIP President and CEO Marilyn Tavenner wrote in a statement. “If changes are made to criteria for who is covered by Medicaid, we need to give people more time to adjust—and more time for the individual market to stabilize.”

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